Erectile dysfunction

Written by: 
Dr Roger Henderson

This page covers:

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erectionThe enlarged, rigid state of the penis during sexual arousal. sufficient to allow satisfactory sexual performance.

Erectile dysfunction is also known as impotence, and is a very common condition, especially in older men. At least half of all men aged between 40 and 70 will experience ED to some degree.

It is a highly embarrassing problem for many men and one that can cause feelings of shame, embarrassment, low self-esteem and relationship difficulties.

If a man wakes with an erectionThe enlarged, rigid state of the penis during sexual arousal. or is able to masturbate normally but finds it difficult to achieve an erectionThe enlarged, rigid state of the penis during sexual arousal. with his usual partner then it is unlikely that the underlying cause is physical

Causes

Erectile dysfunction can be caused by a wide range of problems, both psychological and physical. When sexual arousal occurs, the brain sends signals to the penile nerves and this in turn promotes increased bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. flow to the penis. This causes the penis to harden and expand in size.

It therefore follows that anything that interferes with either the nervous system or the circulation of bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. into the penis can be a potential cause of erectile dysfunctionInability to maintain a penile erection for sexual intercourse..

Physical causes include:

  • Diabetes
  • Heart disease
  • High bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. pressure
  • Hormonal abnormalities.

Psychological problems may include:

  • Anxiety and stressRelating to injury or concern.
  • Depression
  • Relationship problems.

Certain medications may also trigger erectile dysfunctionInability to maintain a penile erection for sexual intercourse.. These include beta blocker tablets (commonly used in the treatment of high bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. pressure), some antidepressants, diuretics (water tablets), steroids and fibrates (drugs used to lower raised cholesterolA substance present in many tissues and an important constituent of cell membranes although high concentrations of a certain type of cholesterol in the blood are unhealthy. levels).

Many men experience an occasional episode of erectile difficulty, which often resolves without needing any treatment or medical assessment.

Typical causes of this include tiredness, temporary relationship problems and excess alcohol. Should erectile dysfunctionInability to maintain a penile erection for sexual intercourse. become more persistent, however, then medical advice should be sought. Erectile dysfunction can also be an early indicator of cardiovascular disease.

Lifestyle factors can also play a part in the development of erectile dysfunctionInability to maintain a penile erection for sexual intercourse.. Obesity, smoking, alcohol, recreational drugs and lack of sleep can all be a trigger here.

One interesting potential cause is cycling. Men who spend more than 3 hours a week cycling may experience a new episode of erectile dysfunctionInability to maintain a penile erection for sexual intercourse. caused by the saddle pressurising the penile nerves while cycling.

As a general point, if a man wakes with an erectionThe enlarged, rigid state of the penis during sexual arousal. or is able to masturbate normally but finds it difficult to achieve an erectionThe enlarged, rigid state of the penis during sexual arousal. with his usual partner then it is unlikely that the underlying cause is physical and it is more likely to be psychological in nature.

Diagnosis

As part of the pathway to diagnosing erectile dysfunctionInability to maintain a penile erection for sexual intercourse., a doctor will ask about symptoms as well as overall physical and mental health.

This history will also include levels of alcohol consumption, smoking history, whether recreational drugs are used, if prescribed medication is being taken and whether any relationship problems are present. You may also be asked whether erectile dysfunctionInability to maintain a penile erection for sexual intercourse. occurs at any time or only with your regular partner.

Examination of the genitals is vital to rule out any physical disorder, and bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. tests can be helpful to check for conditions such as an underactive thyroid glandAn organ with the ability to make and secrete certain fluids. (hypothyroidism), diabetes or low levels of the hormoneA substance produced by a gland in one part of the body and carried by the blood to the organs or tissues where it has an effect. testosterone.

European guidelines recommend the universal measurement of testosterone in erectile dysfunctionInability to maintain a penile erection for sexual intercourse. but this differs from the recommendation of North American guidelines and many family doctors in the UK, for example, who favour selective screening only.

Most men over the age of 40 who go to their doctor with erectile dysfunctionInability to maintain a penile erection for sexual intercourse. should now also be routinely screened for cardiovascular risk (heart attacks, stroke), according to UK guidelines.

Overview of treatment

The treatment of erectile dysfunctionInability to maintain a penile erection for sexual intercourse. depends on the underlying cause of the condition and must be tailored to each individual accordingly. Erectile dysfunction usually responds well to a combination of lifestyle changes and drug treatment.

Whenever possible, the man's partner should be involved in any discussion about possible treatments since erectile dysfunctionInability to maintain a penile erection for sexual intercourse. is a problem that affects both partners

If there is a serious underlying health problem such as diabetes, high blood pressure or heart disease, this should be treated first as this in itself may resolve the problem. Self-help and lifestyle changes are advised in all cases initially. These include:

  • Losing weight if overweight or obese - see weight-loss diets
  • Stopping smoking
  • Avoiding recreational drugs and excessive alcohol consumption
  • Taking regular exercise for at least 30 minutes several times a week.

It is important that any prescribed medication is not suddenly stopped without medical advice being sought. If medication is being taken that could be possibly contributing to erectile dysfunctionInability to maintain a penile erection for sexual intercourse., this should be substituted by your doctor with another drug that does not if possible.

Following any prescribed treatment, most men can be reassured that it is safe to resume a normal and satisfactory sex life.

Medication

The most commonly prescribed treatments in erectile dysfunctionInability to maintain a penile erection for sexual intercourse. are called phosphodiesterase-5 (PDE-5) inhibitors. These are generally tolerated well by men, with few serious side effects. The most commonly prescribed examples of these are sildenafil, tadalafil and vardenafil. They all work by temporarily increasing the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. flow to the penis.

Although PDE-5 inhibitors are very effective, around one quarter of men fail to achieve a satisfactory erectionThe enlarged, rigid state of the penis during sexual arousal. with them. However, increasing the dose may help to overcome this and there is also some evidence that men can respond differently to different types of PDE-5 inhibitors, so different drugs should be tried.

For most men, 'as required' treatment is the most acceptable. This should be started at a low dose and increased if necessary according to response. For the three main drugs used, in practice this means:

  • Sildenafil - take 50mg about 1 hour before planned sexual activity (this time should be increased if taken with food). This dose suits many men but can be increased to 100mg if necessary, or reduced to 25mg if there is kidney or liverA large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. dysfunction
  • Vardenafil - the usual dosage here is 10mg taken around 1 hour before sex. This can be increased to a maximum of 20mg or reduced to 5mg if necessary
  • Tadalafil - this can be taken nearer to sexual activity than the other PDE-5 inhibitors, at 30 minutes beforehand. Taken usually at a dose of 10mg, it can be increased to 20mg if required.

With all these treatments, more than one dose should not be taken in any 24 hour period. They are also not recommended for men who are taking nitrateOne of a class of drugs that dilate the blood vessels. medication or who use the recreational drug amyl nitrateOne of a class of drugs that dilate the blood vessels. (more commonly known as 'poppers'.)

Whenever possible, the man's partner should be involved in any discussion about possible treatments since erectile dysfunctionInability to maintain a penile erection for sexual intercourse. is a problem that affects both partners.

Side effects are not common with PDE-5 inhibitors but can include:

  • Facial flushing
  • Visual disturbances
  • Headaches
  • Indigestion
  • Nasal congestion.

Other treatments

Penis vacuum pump

This simple treatment is essentially a tube connected to a pump that creates a vacuum around the penis and triggers an erectionThe enlarged, rigid state of the penis during sexual arousal.. A rubber band is then placed around the base of the penis to keep the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. in place. In this way, a sustainable erectionThe enlarged, rigid state of the penis during sexual arousal. can be maintained for 15 to 30 minutes.

Alprostodil

This older type of treatment - commonly used before the advent of PDE-5 inhibitors - can be very effective if newer treatments or mechanical aids are unable to be used. It can be injected directly into the penis or introduced into the urethra The tube that carries urine from the bladder, and in men also carries semen during ejaculation.(penis tube) as a small pellet. When effective, erections typically last for between 10 and 30 minutes.

Psychosexual counselling

If the cause of erectile dysfunctionInability to maintain a penile erection for sexual intercourse. is psychological then counselling is often appropriate. This type of relationship therapy allows sexual concerns or difficulties to be aired. Practical advice as to effective foreplay and sexual techniques may be given as well as instruction in how to use pharmacological treatment most effectively.

Surgery

This is an uncommon treatment for erectile dysfunctionInability to maintain a penile erection for sexual intercourse. and is usually only considered if there is clear evidence of a blockage to the penis bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. supply or if all other treatment options have failed. One technique involves using inflatable implants put into the penis for use when needed.